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WHEELCHAIR OPTIONS/ACCESSORIES

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Wheelchair Options/Accessories

Adopted from National Government Services website

For any item to be covered by The Health Plan, it must:

1. Be eligible for a defined Medicare or The Health Plan benefit category

2. Be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve

the functioning of a malformed body member

3. Meet all other applicable Medicare and/or The Health Plan statutory and regulatory

requirements

For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by

the following indications and limitations of coverage and/or medical necessity. Please refer to individual

product lines certificates of coverage for possible exclusions of benefit.

For an item to be covered by The Health Plan, the supplier must receive a written, signed, and dated

order before a claim is submitted to The Health Plan. If the supplier bills for an item addressed in this

policy without first receiving the completed order, the item will be denied as not reasonable and

necessary.

Suppliers are to follow The Health Plan requirements for precertification, as applicable.

Wheelchair options and accessories require precertification and a physician face‐to‐face. For purpose of

this policy, a physician’s order refers to the detailed written order.

CMS National Coverage Policy

CMS Publication 100‐03 Medicare National Coverage

Determinations Manual, Chapter 1, Section 280.1,

280.3

DME Region LCD Covers Jurisdiction B‐C

Revision/Review Effective Date

For services performed on or after 10/31/13

Review/Revised: 04/21/17, 02/15/17, 10/04/16,

01/01/2016, 10/01/14

The Health Plan

Plans will follow Coverage Determination posted on

the CGS website unless otherwise indicated in

sections of this policy, contractual agreements, or

benefit plan documents.

DESCRIPTION

Items provided, in addition to the basic wheelchair base.


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COVERAGE GUIDELINES

Options and accessories for wheelchairs are covered if the member has a wheelchair that meets

Medicare coverage criteria and the option/accessory itself is medically necessary. Coverage criteria for

specific items are described below.

ARM OF CHAIR

Adjustable arm height option (E0973, K0017, K0018, and K0020) is covered if the member requires an

arm height that is different than that available using nonadjustable arms and the patient spends at least

two hours per day in the wheelchair. K0017 and K0018 are replacements and are not separately billable

at initial issue of the wheelchair.

An arm trough (E2209) is covered if the member has quadriplegia, hemiplegia, or uncontrolled arm

movements.

FOOT REST/LEG REST

Elevating leg rests (E0990, K0046, K0047, K0053, and K0195) are covered if:

1. The member has a musculoskeletal condition or the presence of a cast or brace which prevents

90° flexion at the knee; or

2. The member has significant edema of the lower extremities that requires an elevating leg rest;

or

3. The member meets the criteria for and has a reclining back on the wheelchair.

NONSTANDARD SEAT FRAME DIMENSIONS

A nonstandard seat width and/or depth for a manual wheelchair (E2201 ‐ E2204) is covered only if the

member's physical dimensions justify the need.

WHEELS/TIRES FOR MANUAL WHEELCHAIRS

A gear reduction drive wheel (E2227) or a lever activated wheel drive (E0988) is covered if all of the

following criteria are met:

1. The member has been self‐propelling in a manual wheelchair for at least one year; and

2. The member has had a specialty evaluation that was performed by a licensed/certified medical

professional, such as a PT or OT, or physician who has specific training and experience in

rehabilitation wheelchair evaluations and that documents the need for the device in the

member’s home. The PT, OT, or physician may have no financial relationship with the supplier;

and

3. The wheelchair is provided by a supplier that employs a RESNA‐certified Assistive Technology

Professional (ATP) who specializes in wheelchairs and who has direct, in‐person involvement in

the wheelchair selection for the member.


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BATTERIES/CHARGERS

Up to two sealed batteries (E2359, E2361, E2363, E2365, E2371, and K0733) at any one time are allowed

if required for a power wheelchair.

A single mode battery charger (E2366) is appropriate for charging sealed lead acid battery.

The usual maximum frequency of replacement for a lithium‐based battery (E2397) is one every three

years. Only one battery is allowed at any one time.

POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1002 ‐ E1010)

A power seating system – tilt only, recline only, or combination tilt and recline – with or without power

elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met:

1. The member meets all the coverage criteria for a power wheelchair described in the power

mobility devices policy; and

2. A specialty evaluation by a licensed/certified medical professional, such as a PT or OT or

physician who has specific training and experience in rehabilitation wheelchair evaluations of

the member’s seating and positioning needs. The PT, OT, or physician may have no financial

relationship with the supplier; and

3. The wheelchair is provided by a supplier that employs a RESNA‐certified Assistive Technology

Professional (ATP) who specializes in rehabilitation wheelchairs and who has direct, in‐person

involvement in the selection of the seating system for the member; and

4. The member is at high risk for development of a pressure ulcer and is unable to perform a

functional weight shift; or

5. The member utilizes intermittent catheterization for bladder management and is unable to

independently transfer from the wheelchair to bed; or

6. The power seating system is needed to manage increased tone or spasticity.

POWER WHEELCHAIR DRIVE CONTROL SYSTEMS

An attendant control is covered in place of a patient‐operated drive control system if the member meets

coverage criteria for a wheelchair, is unable to operate a manual or power wheelchair and has a

caregiver who is unable to operate a manual wheelchair but is able to operate a power wheelchair.

OTHER POWER WHEELCHAIR ACCESSORIES

An electronic interface (E2351) to allow a speech generating device to be operated by the power

wheelchair control interface is covered if the member has a covered speech generating device. (See

speech generating devices.)


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MISCELLANEOUS ACCESSORIES

Anti‐rollback device (E0974) is covered if the member self‐propels and needs the device because of

ramps.

A safety belt/pelvic strap (E0978) is covered if the member has weak upper body muscles, upper body

instability or muscle spasticity which requires use of this item for proper positioning.

One example (not all‐inclusive) of a covered indication for swingaway, retractable, or removable

hardware (E1028) would be to move the component out of the way so that a member can perform a

slide transfer to a chair or bed.

A manual fully reclining back option (E1226) is covered if the member has one or more of the following

conditions:

1. The member is at high risk for development of a pressure ulcer and is unable to perform a

functional weight shift; or

2. The member utilizes intermittent catheterization for bladder management and is unable to

independently transfer from the wheelchair to the bed.

For information concerning a push‐rim activated power assist device for a manual wheelchair, refer to

the power mobility devices medical policy.

NONCOVERAGE STATEMENT

A non‐sealed battery (E2358, E2360, E2362, E2364, and E2372) will be denied as not medically

necessary.

If a dual mode battery charger (E2367) is provided as a replacement, it will be denied as not reasonable

and necessary.

The following features of a power wheelchair will be denied as noncovered: stair climbing (A9270),

electronic balance (A9270), ability to elevate the seat by balancing on two wheels (A9270), and remote

operation (A9270).

An option/accessory that is beneficial, primarily in allowing the member to perform leisure or

recreational activities, is noncovered.

A power seat elevation feature (E2300) and power standing feature (E2301) are noncovered because

they are not primarily medical in nature.

If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole

function of the connection is for a power seat elevation or power standing feature, it will be denied as

noncovered.

An electronic interface used to control lights or other electrical devices is noncovered because it is not

primarily medical in nature.

Swingaway, retractable, or removable hardware (E1028) is noncovered if the primary indication for its

use is to allow the member to move close to desks or other surfaces. If it ordered for this indication, a

GY modifier must be added to the code.


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A manual standing system for a manual wheelchair (E2230) is noncovered (no benefit category) because

it is not primarily medical in nature.

Codes E0968, E0969, E0970, E0980, E0994, E1227, E1228, E1296 ‐ E1298, and E2340 ‐ E2343 are not

valid for claim submission.

An electronic interface (E2352) that is used to allow lights or other electrical devices to be operated

using the power wheelchair control interface must be billed with code A9270 (non‐covered item).

REPAIR AND REPLACEMENT

See specific item.

May also refer to repair and replacement policy.

Requests for replacement (modifier RP) option/accessories should include the medical necessity for the

item as indicated in documentation requirements below. Include make and model name of the

wheelchair base it is being added to, and the date of initial issue of the wheelchair.

Codes E2368 ‐ E2370 are for a replacement motor and/or gearbox. These codes are not used at the time

of initial issue. If the item is a rebuilt component, the UE (used DME) modifier must be added to the

code.

To bill a repair of a cantilever armrest use code K0108‐ Wheelchair component or accessory, not

otherwise specified. This code includes all parts necessary to repair or replace the armrest.


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CODING INFORMATION

CPT/HCPCS codes: The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS

EY NO PHYSICIAN OR OTHER LICENSED HEALTH CARE PROVIDER ORDER FOR THIS ITEM OR

SERVICE

GA WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYOR POLICY, INDIVIDUAL

CASE

GY ITEM OR SERVICE STATUTORILY EXCLUDED OR DOES NOT MEET THE DEFINITION OF ANY

MEDICARE BENEFIT

GZ ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARY

KC REPLACEMENT OF SPECIAL POWER WHEELCHAIR INTERFACE

KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET

RB REPLACEMENT OF A PART OF DME FURNISHED AS PART OF A REPAIR

HCPCS CODES

ARM OF CHAIR

E0973 WHEELCHAIR ACCESSORY, ADJUSTABLE HEIGHT, DETACHABLE ARMREST, COMPLETE

ASSEMBLY, EACH

E2209 ACCESSORY, ARM TROUGH, WITH OR WITHOUT HAND SUPPORT, EACH

E2626 WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARM SUPPORT ATTACHED TO

WHEELCHAIR, BALANCED, ADJUSTABLE


WHEELCHAIR, BALANCED, ADJUSTABLE RANCHO TYPE


WHEELCHAIR, BALANCED, RECLINING

E2629

WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARMS SUPPORT ATTACHED TO

WHEELCHAIR, BALANCED, FRICTION ARM SUPPORT(FRICTION DAMPENING TO PROXIMAL

AND DISTAL JOINTS

E2630

WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARM SUPPORT, MONOSUSPENSION

ARM AND HAND SUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE

TYPE SUSPENSION SUPPORT

E2631 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL

ARM


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E2632 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL

ROCKER ARM WITH ELEASTIC BALANCE CONTROL

E2633 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR

K0015 DETACHABLE, NON‐ADJUSTABLE HEIGHT ARMREST, REPLACEMENT ONLY, EACH

K0017 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, BASE, REPLACEMENT ONLY, EACH

K0018 DETACHABLE, ADJUSTABLE HEIGHT ARMREST, UPPER PORTION, REPLACEMENT ONLY, EACH

K0019 ARM PAD, REPLACEMENT ONLY, EACH

K0020 FIXED, ADJUSTABLE HEIGHT ARMREST, PAIR

HCPCS CODES

FOOT REST/LEG REST

E0951 HEEL LOOP/HOLDER, ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH

E0952 TOE LOOP/HOLDER, ANY TYPE, EACH

E0990 WHEELCHAIR ACCESSORY, ELEVATING LEG REST, COMPLETE ASSEMBLY, EACH

E0995 WHEELCHAIR ACCESSORY, CALF REST/PAD, REPLACEMENT ONLY,EACH

E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR, ANY TYPE

K0037 HIGH MOUNT FLIP‐UP FOOTREST, REPLACEMENT ONLY, EACH

K0038 LEG STRAP, EACH

K0039 LEG STRAP, H STYLE, EACH

K0040 ADJUSTABLE ANGLE FOOTPLATE, EACH

K0041 LARGE SIZE FOOTPLATE, EACH

K0042 STANDARD SIZE FOOTPLATE, REPLACEMENT ONLY, EACH

K0043 FOOTREST, LOWER EXTENSION TUBE, REPLACEMENT ONLY, EACH

K0044 FOOTREST, UPPER HANGER BRACKET, REPLACEMENT ONLY, EACH

K0045 FOOTREST, COMPLETE ASSEMBLY, REPLACEMENT ONLY, EACH

K0046 ELEVATING LEGREST, LOWER EXTENSION TUBE, REPLACEMENT, EACH

K0047 ELEVATING LEGREST, UPPER HANGER BRACKET, REPLACEMENT ONLY, EACH

K0050 RATCHET ASSEMBLY, REPLACEMENT ONLY

K0051 CAM RELEASE ASSEMBLY, FOOTREST OR LEGREST, REPLACEMENT ONLY, EACH

K0052 SWINGAWAY, DETACHABLE FOOTRESTS, REPLACEMENT ONLY, EACH


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K0053 ELEVATING FOOTRESTS, ARTICULATING (TELESCOPING), EACH

K0195 ELEVATING LEG RESTS, PAIR (FOR USE WITH CAPPED RENTAL WHEELCHAIR BASE)

HCPCS CODES


E1011 MODIFICATION TO PEDIATRIC SIZE WHEELCHAIR, WIDTH ADJUSTMENT PACKAGE (NOT TO

BE DISPENSED WITH INITIAL CHAIR)

E2201 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME, WIDTH GREATER THAN

OR EQUAL TO 20 INCHES AND LESS THAN 24 INCHES

E2202 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME WIDTH, 24‐27 INCHES

E2203 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 20 TO LESS THAN

22 INCHES

E2204 MANUAL WHEELCHAIR ACCESSORY, NONSTANDARD SEAT FRAME DEPTH, 22 TO 25 INCHES

K0056 SEAT HEIGHT LESS THAN 17" OR EQUAL TO OR GREATER THAN 21" FOR A HIGH STRENGTH,

LIGHTWEIGHT, OR ULTRALIGHTWEIGHT WHEELCHAIR

HCPCS CODES

REAR WHEELS FOR MANUAL WHEELCHAIRS

E0961 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK BRAKE EXTENSION (HANDLE), EACH

E0967 MANUAL WHEELCHAIR ACCESSORY, HAND RIM WITH PROJECTIONS, ANY TYPE,

REPLACEMENT ONLY, EACH

E0988 MANUAL WHEELCHAIR ACCESSORY, LEVER‐ACTIVATED, WHEEL DRIVE, PAIR

E2205 MANUAL WHEELCHAIR ACCESSORY, HANDRIM WITHOUT PROJECTIONS (INCLUDES

ERGONOMIC OR CONTOURED), ANY TYPE, REPLACEMENT ONLY, EACH

E2206 MANUAL WHEELCHAIR ACCESSORY, WHEEL LOCK ASSEMBLY, COMPLETE, REPLACEMENT

ONLY, EACH

E2211 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC PROPULSION TIRE, ANY SIZE, EACH

E2212 MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC PROPULSION TIRE, ANY SIZE,

EACH

E2213 MANUAL WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC PROPULSION TIRE

(REMOVABLE), ANY TYPE, ANY SIZE, EACH

E2214 MANUAL WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, EACH


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E2215 MANUAL WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, EACH

E2216 MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED PROPULSION TIRE, ANY SIZE, EACH

E2217 MANUAL WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, EACH

E2218 MANUAL WHEELCHAIR ACCESSORY, FOAM PROPULSION TIRE, ANY SIZE, EACH

E2219 MANUAL WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, EACH

E2220 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) PROPULSION TIRE, ANY SIZE,


E2221 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE),

ANY SIZE, REPLACEMENT ONLY, EACH

E2222 MANUAL WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH

INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY,EACH

E2224 MANUAL WHEELCHAIR ACCESSORY, PROPULSION WHEEL EXCLUDES TIRE, ANY SIZE,


E2225 MANUAL WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE,


E2226 MANUAL WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH

E2227 MANUAL WHEELCHAIR ACCESSORY, GEAR REDUCTION DRIVE WHEEL, EACH

E2228 MANUAL WHEELCHAIR ACCESSORY, WHEEL BRAKING SYSTEM AND LOCK, COMPLETE, EACH

K0065 SPOKE PROTECTORS, EACH

K0069 REAR WHEEL ASSEMBLY, COMPLETE, WITH SOLID TIRE, SPOKES OR MOLDED, REPLACEMENT

ONLY, EACH

K0070 REAR WHEEL ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, SPOKES OR MOLDED,


K0071 FRONT CASTER ASSEMBLY, COMPLETE, WITH PNEUMATIC TIRE, REPLACEMENT ONLY, EACH

K0072 FRONT CASTER ASSEMBLY, COMPLETE, WITH SEMI‐PNEUMATIC TIRE, REPLACEMENT ONLY,

EACH

K0073 CASTER PIN LOCK, EACH

K0077 FRONT CASTER ASSEMBLY, COMPLETE, WITH SOLID TIRE, REPLACEMENT ONLY, EACH

HCPCS CODES

BATTERIES/CHARGERS

E2358 POWER WHEELCHAIR ACCESSORY, GROUP 34 NON‐SEALED LEAD ACID BATTERY, EACH


10

E2359 POWER WHEELCHAIR ACCESSORY, GROUP 34 SEALED LEAD ACID BATTERY, EACH (E.G. GEL

CELL, ABSORBED GLASSMAT)

E2360 POWER WHEELCHAIR ACCESSORY, 22 NF NON‐SEALED LEAD ACID BATTERY, EACH

E2361 POWER WHEELCHAIR ACCESSORY, 22NF SEALED LEAD ACID BATTERY, EACH, (E.G. GEL



E2363 POWER WHEELCHAIR ACCESSORY, GROUP 24 SEALED LEAD ACID BATTERY, EACH (E.G. GEL


E2364 POWER WHEELCHAIR ACCESSORY, U‐1 NON‐SEALED LEAD ACID BATTERY, EACH

E2365 POWER WHEELCHAIR ACCESSORY, U‐1 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL,

ABSORBED GLASSMAT)

E2366 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, SINGLE MODE, FOR USE WITH

ONLY ONE BATTERY TYPE, SEALED OR NON‐SEALED, EACH

E2367 POWER WHEELCHAIR ACCESSORY, BATTERY CHARGER, DUAL MODE, FOR USE WITH

EITHER BATTERY TYPE, SEALED OR NON‐SEALED, EACH

E2371 POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL,

ABSORBED GLASSMAT), EACH


E2397 POWER WHEELCHAIR ACCESSORY, LITHIUM‐BASED BATTERY, EACH

K0733 POWER WHEELCHAIR ACCESSORY, 12 TO 24 AMP HOUR SEALED LEAD ACID BATTERY,

EACH (E.G., GEL CELL, ABSORBED GLASSMAT)


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HCPCS CODES

POWER SEATING SYSTEMS

E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY

E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR

REDUCTION

E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL

SHEAR REDUCTION

E1005 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH POWER SHEAR

REDUCTION

E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE,

WITHOUT SHEAR REDUCTION


WITH MECHANICAL SHEAR REDUCTION


WITH POWER SHEAR REDUCTION

E1009 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY

LINKED LEG ELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACH

E1010 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG

ELEVATION SYSTEM, INCLUDING LEG REST, PAIR

E1012 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM,CENTER MOUNT

POWER ELEVATING LEG REST/PLATFORM,COMPLETE SYSTEM,ANY TYPE ,EACH

E2300 POWER WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM, ANY TYPE

E2301 POWER WHEELCHAIR ACCESSORY, POWER STANDING SYSTEM, ANY TYPE

E2310

POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR

CONTROLLER AND ONE POWER SEATING SYSTEM MOTOR, INCLUDING ALL RELATED

ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND

FIXED MOUNTING HARDWARE

E2311

POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR

CONTROLLER AND TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL

RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION

SWITCH, AND FIXED MOUNTING HARDWARE


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HCPCS CODES


E2312

POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI‐

PROPORTIONAL REMOTE JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING

HARDWARE

E2313 POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER,

INCLUDING ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH

E2321

POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK,

NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH,

AND FIXED MOUNTING HARDWARE

E2322

POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL

SWITCHES, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL

STOP SWITCH, AND FIXED MOUNTING HARDWARE

E2323 POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROL

INTERFACE, PREFABRICATED

E2324 POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACE

E2325

POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL,

INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL

SWINGAWAY MOUNTING HARDWARE

E2326 POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE

E2327

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL,

PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE

SWITCH, AND FIXED MOUNTING HARDWARE

E2328

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE,

ELECTRONIC, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED

MOUNTING HARDWARE

E2329

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH

MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL

STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED

MOUNTING HARDWARE

E2330

POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH

MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL

STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED

MOUNTING HARDWARE

E2331 POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, PROPORTIONAL, INCLUDING ALL

RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE


13

E2373 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, COMPACT REMOTE

JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE

E2374

POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, STANDARD

REMOTE JOYSTICK (NOT INCLUDING CONTROLLER), PROPORTIONAL, INCLUDING ALL

RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE, REPLACEMENT ONLY

E2375 POWER WHEELCHAIR ACCESSORY, NON‐EXPANDABLE CONTROLLER, INCLUDING ALL

RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY

E2376 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED

ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY

E2377 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED

ELECTRONICS AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE

HCPCS CODES

OTHER POWER WHEELCHAIR ACCESSORIES

E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH

E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY POWER

WHEELCHAIR, EACH

E2351 POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH

GENERATING DEVICE USING POWER WHEELCHAIR CONTROL INTERFACE

E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY

E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY

E2370 POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX

COMBINATION, REPLACEMENT ONLY

E2378 POWER WHELLCHAIR COMPONENT, ACTUATOR, REPLACEMENT ONLY

E2381 POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE,


E2382 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE,


E2383 POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE

(REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH

E2384 POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT

ONLY, EACH

E2385 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE,



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E2386 POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE,


E2387 POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT

ONLY, EACH

E2388 POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT

ONLY, EACH

E2389 POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY,

EACH

E2390 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE,


E2391 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE),

ANY SIZE, REPLACEMENT ONLY, EACH

E2392 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH

INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH

E2394 POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT

ONLY, EACH

E2395 POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE,


E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH

K0098 DRIVE BELT FOR POWER WHEELCHAIR, REPLACEMENT ONLY

HCPCS CODES

MISCELLANEOUS ACCESSORIES

A9270 NON‐COVERED ITEM OR SERVICE

A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER

HCPCS CODE

E0705 TRANSFER DEVICE, ANY TYPE, EACH

E0950 WHEELCHAIR ACCESSORY, TRAY, EACH

E0958 MANUAL WHEELCHAIR ACCESSORY, ONE‐ARM DRIVE ATTACHMENT, EACH

E0959 MANUAL WHEELCHAIR ACCESSORY, ADAPTER FOR AMPUTEE, EACH

E0971 MANUAL WHEELCHAIR ACCESSORY, ANTI‐TIPPING DEVICE, EACH

E0974 MANUAL WHEELCHAIR ACCESSORY, ANTI‐ROLLBACK DEVICE, EACH

E0978 WHEELCHAIR ACCESSORY, POSITIONING BELT/SAFETY BELT/PELVIC STRAP, EACH


15

E0981 WHEELCHAIR ACCESSORY, SEAT UPHOLSTERY, REPLACEMENT ONLY, EACH

E0982 WHEELCHAIR ACCESSORY, BACK UPHOLSTERY, REPLACEMENT ONLY, EACH

E0985 WHEELCHAIR ACCESSORY, SEAT LIFT MECHANISM

E1014 RECLINING BACK, ADDITION TO PEDIATRIC SIZE WHEELCHAIR

E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR, EACH

E1017 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY DUTY MANUAL

WHEELCHAIR, EACH

E1028

WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE

MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING

ACCESSORY

E1029 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, FIXED

E1030 WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED

E1225 WHEELCHAIR ACCESSORY, MANUAL SEMI‐RECLINING BACK, (RECLINE GREATER THAN 15

DEGREES, BUT LESS THAN 80 DEGREES), EACH

E1226 WHEELCHAIR ACCESSORY, MANUAL FULLY RECLINING BACK, (RECLINE GREATER THAN 80

DEGREES), EACH

E2207 WHEELCHAIR ACCESSORY, CRUTCH AND CANE HOLDER, EACH

E2208 WHEELCHAIR ACCESSORY, CYLINDER TANK CARRIER, EACH

E2210 WHEELCHAIR ACCESSORY, BEARINGS, ANY TYPE, REPLACEMENT ONLY, EACH

E2230 MANUAL WHEELCHAIR ACCESSORY, MANUAL STANDING SYSTEM

E2295 MANUAL WHEELCHAIR ACCESSORY, FOR PEDIATRIC SIZE WHEELCHAIR, DYNAMIC SEATING

FRAME, ALLOWS COORDINATED MOVEMENT OF MULTIPLE POSITIONING FEATURES

K0105 IV HANGER, EACH

K0108 WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED

There are no specific diagnoses or ICD‐10 codes that indicate medical necessity.

DOCUMENTATION REQUIREMENTS

For the purposes of this policy it is expected that the medical record will support the need for the care

provided. It is generally understood that the medical record includes the physician's office records,

hospital records, nursing home records, home health agency records, records from other health care

professionals and test reports.

The following information must be submitted at the time of precertification.

1. Physician 7 – element order.

a. Physician signature ‐ with date. Date stamps are not appropriate


16

2. Detailed product description and detailed written order. Order must include any specific feature

of the base code and every addition requested. The medical record must contain the

information that supports the request for each item, and must be submitted with the

precertification, if the items requires precertification, or with the claim, if no precertification

was required.

3. Clinical from physician face‐to‐face should include information on why the patient needs the

item, the member's diagnosis, the member’s abilities and limitations as they relate to the

equipment (e.g., degree of independence/dependence, frequency and nature of the activities

the member performs, etc.), the duration of the condition, the expected prognosis, and past

experience using similar equipment, and any cognitive impairment.

4. Home evaluation by the DME provider

5. Proof of delivery to be kept on file by the provider of the item.

Note: If templates or forms are submitted, (e.g., A Medicare Certificate of Medical Necessity,

and /or a provider created form), The Health Plan reserves the right to request the medical

record that may include, but not limited to, the physician office notes, hospital and nursing

facility records, home health records.

Note: Template provider forms, prescriptions, and attestation letters are not considered part of

the medical record, even if signed by the ordering physician.

Providers are reminded to meet the requirements specified in CMS Program Integrity Manual (Internet‐

Only Manual, Pub. 100‐8), Chapter 5. There must be sufficient detail to identify the item(s) in order to

determine that the item was properly coded.

For The Health Plan member’s, items provided for a power mobility device other than at the time of initial

issue require precertification. Please include physician’s order detailing each item requested. Also include

reason being provided, i.e., replacement d/t damage from wear and tear, accident, natural disaster,

reasonable useful lifetime exceeded, etc.

For manual wheelchair accessories, the detailed written order which lists each item which will be billed

separately and which is signed and dated by the physician and must be received by the supplier and

submitted with precertification.

FOR OPTIONS OR ACCESSORIES PROVIDED WHILE MEMBER IN A PART A COVERED STAY

Reimbursement of any wheelchair options or accessories while member is in a part a facility stay will be

based on individual facility contracts and whether or not the item will be necessary for home going. See

manual wheelchair or power operated vehicles.


17

BILLING GUIDELINES

Accessories to the wheelchair base must be billed on the same claim as the wheelchair base itself.

If an option or accessory that is included in another code is billed separately, the claim line will be

denied as not separately payable.

A sealed battery (E2359, E2361, E2363, E2365, E2371, E2397, K0733) is separately payable from a

power wheelchair base.

There is no additional/separate payment when a dual mode battery charger is provided at the time of

initial issue of a power wheelchair.

A battery charger (E2366, E2367) is included in the allowance for a power wheelchair base

If an attendant control (E2331) is provided in addition to a patient‐operated drive control system, it will

be denied as noncovered. See coverage guidelines when it is provided in place of a member‐operated

system.

Elevating leg rests that are used with a wheelchair that is purchased or owned by the patient are coded

E0990. This code is per leg rest. Elevating leg rests that are used with a capped rental wheelchair base

are coded K0195. This code is per pair of leg rests.

The RB modifier is used when an option or accessory is provided as a replacement for the same part

which has been worn or damaged (e.g., replacing a tire of the same type). The RB modifier must not be

used for an upgrade subsequent to providing the wheelchair base (e.g., replacing a standard seat of a

power wheelchair with a power seating system). The RB modifier must not be used if the accessory is

provided at the same time as the wheelchair base, even if the option/accessory is the same as one that

the patient had on a prior wheelchair. See section on power wheelchair drive control systems for

instructions on the use of the KC replacement modifier.

Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific

HCPCS code and are not included in another code should be coded K0108. If multiple miscellaneous

accessories are provided, each should be billed on a separate claim line using code K0108. When billing

more than one line item with code K0108, ensure that the additional information can be matched to the

appropriate line item on the claim. It is also helpful to reference the line item to the submitted charge. If

a supplier chooses to bill separately for a component that is included in another code, code A9900 must

be used.

The right (RT) and left (LT) modifiers must be used when appropriate. If bilateral items (left and right)

are provided as a purchase and the unit of service of the code is “each” bill both items on the same

claim line using the LTRT modifiers and two units of service. If bilateral items are provided as a rental

and the unit of service is “each,” bill the items on two separate claim lines with the RT modifier on one

line and the LT modifier on the other. If bilateral items are provided and the unit of service is a “pair,”

the LT and RT modifiers do not need to be reported.

The table below defines the bundling guidelines for wheelchair bases and options/accessories. Codes

listed in Column II are not separately payable from the wheelchair base and must not be billed

separately at the time of initial purchase or rental of the wheelchair.


18

A Column II code is included in the allowance for the corresponding Column I code when provided at the

same time. When multiple codes are listed in Column I, all the codes in Column II relate to each code in

Column I.

Column I Column II

Power Operated Vehicle

(K0800‐K0812) All Options & Accessories

Rollabout Chair (E1031) All Options & Accessories

Transport Chair

(E1037, E1038, E1039) All Options & Accessories Except E0990, K0195

Manual Wheelchair Base

(E1161, E1229, E1231, E1232,

E1233, E1234, E1235, E1236,

E1237, E1238, K0001, K0002,

K0003, K0004, K0005, K0006,

K0007, K0009)

E0967, E0981, E0982, E0995, E2205, E2206, E2210, E2220,

E2221, E2222, E2224, E2225, E2226, K0015, K0017, K0018,

K0019, K0042, K0043, K0044, K0045, K0046, K0047, K0050,

K0052, K0069, K0070, K0071, K0072, K0077

Power Wheelchair Base

Groups 1 and 2

(K0813‐K0843)

E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367,

E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381,

E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389,

E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017,

K0018, K0019, K0037, K0040, K0041, K0042, K0043, K0044,

K0045, K0046, K0047, K0051, K0052, K0077, K0098

Power Wheelchair Base

Groups 3, 4, and 5

(K0848‐K0891)

E0971, E0978, E0981, E0982, E0995, E1225, E2366, E2367,

E2368, E2369, E2370, E2374, E2375, E2376, E2378, E2381,

E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389,

E2390, E2391, E2392, E2394, E2395, E2396, K0015, K0017,

K0018, K0019, K0037, K0041, K0042, K0043, K0044, K0045,

K0046, K0047, K0051, K0052, K0077, K0098

E0973 K0017, K0018, K0019

E0950 E1028

E0990 E0995, K0042, K0043, K0044,

K0045, K0046, K0047

Power Tilt and/or Recline

Seating Systems

(E1002, E1003, E1004, E1005,

E1006, E1007, E1008)

E0973, K0015, K0017, K0018, K0019, K0020, K0042, K0043,

K0044, K0045, K0046, K0047, K0050, K0051, K0052


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E1009, E1010 E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047,

K0052, K0053, K0195

E1020 E1028

E2325 E1028

K0039 K0038

K0045 K0043, K0044

K0046 K0043

K0047 K0044

K0053 E0990, E0995, K0042, K0043, K0044, K0045, K0046, K0047

K0069 E2220, E2224

K0070 E2211, E2212, E2224

K0071 E2214, E2215, E2225, E2226

K0072 E2219, E2225, E2226

K0077 E2221, E2222, E2225, E2226

K0195 E0995, K0042, K0043, K0044, K0045, K0046, K0047

POWER WHEELCHAIR EQUIPMENT PACKAGE

Each power wheelchair code is required to include all these items on initial issue (i.e., no separate

billing/payment at the time of initial issue, unless otherwise noted).

Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately.

Battery charger, single mode.

Complete set of tires and casters, any type.

Leg rests. There is no separate billing/payment if fixed, swingaway, or detachable nonelevating

leg rests with or without calf pad are provided. Elevating leg rests may be billed separately.

Foot rests/foot platform. There is no separate billing/payment if fixed, swingaway, or

detachable footrests or a foot platform without angle adjustment are provided. There is no

separate billing for angle adjustable footplates with Group 1 or 2 PWC. Angle adjustable

footplates may be billed separately with Group 3, 4 and 5 PWC.

Arm rests. There is no separate billing/ payment if fixed, swingaway, or detachable non‐

adjustable height arm rests with arm pad (K0015) are provided. Adjustable height arm rests (

K0020) may be billed separately.

Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as

required by patient weight capacity.

Any seat width and depth. Exception: for Group 3 and 4 PWC with a sling/solid seat/back, the

following may be billed separately:


20

For standard duty, seat width and/or depth greater than 20 in.

For heavy‐duty, seat width and/or depth greater than 22 in.

For very heavy‐duty, seat width and/or depth greater than 24 in.

For extra heavy‐duty, no separate billing

Any back width. Exception: for Group 3 and 4 PWC with a sling/solid seat/back, the following

may be billed separately:





Controller and input device. There is no separate billing/payment if a non‐expandable controller

and a standard proportional joystick (integrated or remote) is provided. An expandable

controller, a nonstandard joystick (i.e., nonproportional or mini, compact or short throw

proportional), or other alternative control device may be billed separately.

POWER OPERATED VEHICLE EQUIPMENT PACKAGE

All options and accessories, except for shoulder harness or chest straps , provided at the time of initial

issue of a POV are not separately billable.

POV Basic Equipment Package ‐ Each POV is to include all these items on initial issue (i.e., no separate

billing/payment at time of initial issue):

Battery or batteries required for operation

Battery charger, single mode

Lap belt/seat belt.

Weight appropriate upholstery and seating system

Tiller steering

Non‐expandable controller with proportional response to input

Complete set of tires

All accessories needed for safe operation.

A replacement option/accessory for POV is billed using a wheelchair option/accessory code. Medically

necessary replacement items are covered

ROLLABOUT CHAIR BUNDLING OF ACCESSORIES

The allowance for a rollabout chair includes all options and accessories that are provided at the time of

initial issue. Accessories provided at the time of initial issue of a rollabout chair are not separately

billable.

The allowance for a transport chair includes all options and accessories that are provided at the time of

initial issue except for elevating leg rests (E0990, K0195).

If a rollabout chair or transport chair are covered, medically necessary replacement items are covered.

A replacement accessory for a rollabout or transport chair is billed using code E1399.



21

For all adult manual wheelchairs (E1161, K0001 ‐ K0009), payment for seat widths and/or seat depths of

15‐19 in. is included in the payment for the base code. These seat dimensions should not be billed

separately. Codes E2201 ‐ E2204 describe seat widths and/or depths of 20 in. or more for manual

wheelchairs.

For power wheelchairs, there is no separate billing for nonstandard seat frame dimensions (width,

depth, or height) with the following exceptions: for Group 3 and 4 power wheelchairs, with a sling/solid

seat/back, the following items may be billed separately using code K0108:





For Group 3 and 4 PWC with a sling/solid seat/back, the following items may be billed separately using

code K0108:





Code K0108 may not be billed for nonstandard dimensions of a power tilt and/or recline seating system

(E1002 ‐ E1008). The definition of those codes includes any frame width and depth.

Code K0108 is appropriately used at the time of initial issue only when the drive control interface that is

provided is not included in the base code and there is no specific E code which describes it.

Code K0108 is appropriately used at the time of replacement in the following situations:

1. An integrated proportional joystick and controller box are being replaced due to damage; or

2. An interface other than a remote joystick (e.g., sip and puff, head control) is being replaced but

the controller is not being replaced; or

3. There is no specific E code which describes the type of drive control interface system which is

provided.

The KC modifier (replacement of special power wheelchair interface) is used in the following situations:

1. Due to a change in the member's condition an integrated joystick and controller is being

replaced by another drive control interface ‐ e.g., remote joystick, head control, sip and puff,

etc.; or

2. The member had a drive control interface described by codes E2321 ‐ E2322, E2325, E2327 ‐

E2330, or E2373 and both the interface (e.g., joystick, head control, sip, and puff) and the

controller electronics are being replaced due to irreparable damage.

The KC modifier would never be used at the time of initial issue of a wheelchair. The KC modifier

specifically states replacement, therefore, the RB modifier is not required.

SWINGAWAY ITEMS

Code E1028 is used for


22

1. Swingaway hardware used with remote joysticks or touchpads

2. Swingaway or flip‐down hardware for head control interfaces E2327 ‐ E2330

3. Swingaway hardware for an indicator display box that is related to the multi‐motor electronic

connection codes E2310 or E2311.

Code E1028 is not to be used for swingaway hardware used with a sip and puff interface (E2325)

because swingaway hardware is included in the allowance for that code. See wheelchair seating policy

for information concerning uses of E1028 for positioning accessories. E1028 is not to be used for

hardware on a wheelchair tray (E0950).

This hardware can be used with many components on a power wheelchair. Multiple items may be billed

on the same claim using this code.

When submitting a claim with multiple items that must be coded with HCPCS code E1028, the following

instructions must be applied.

Each different item (i.e., swingaway hardware for a medial thigh support, swingaway hardware

for lateral trunk supports, retractable joystick mount, etc.) billed as an E1028 must be submitted

on a separate claim line.

Each E1028 claim line must include a narrative description of the item, including the brand name,

make/model, and the part number.

HCPCS code E1028 is included in the reimbursement with HCPCS code E1020 (residual limb support) and

not separately payable.

KX, GA, and GZ MODIFIERS

1. Use the GY modifier for the accessories for a power mobility device, if the requirements related

to a 7‐element order and face‐to‐face examination in the power mobility devices policy article

has not been met.

2. For accessories provided with a manual wheelchair or power mobility device, if it is only needed

for mobility outside the home, the GY modifier must be added to the codes for all accessories.

3. The KX modifier must be added to the code for the accessory only if:

a. The coverage criteria indicated in the manual wheelchair bases or power mobility

devices policies have been met and

b. Any specific coverage criteria for the accessory in this policy have been met

ADVANCED BENEFICIARY NOTICE

The Health Plan expects providers to follow the Medicare policy on ABN across all Medicare, Medicaid,

and Commercial plans.

NOTE: Providers may be held financially responsible if they furnish the above items without notifying

the member, verbally and in writing, that the specific service being provided is not covered. This must be

done prior to the dispensing of the device. The provider must submit the waiver or Advanced

Beneficiary Notification (ABN) to The Health Plan with the claim showing the member agreed to pay for

the device. Generalized statements on waivers or ABN are not acceptable.


23

PRICING, DATA ANALYSIS, AND CODING (PDAC)

The Health Plan has implemented use of Medicare’s PDAC contractor for review of authorizations.

Suppliers should contact the PDAC contractor for guidance on the correct coding of these items.

dmepdac.com/

MEDICARE DEFINITIONS AND DESCRIPTION

WHEELS/TIRES FOR MANUAL WHEELCHAIRS

A propulsion wheel is a large wheel which can be used by a beneficiary to propel the wheelchair with

his/her arms.

A caster is a small wheel that is in contact with the ground during normal operation of the wheelchair

and which cannot be used for arm propulsion. This includes rear tires on tilt‐in‐space wheelchairs that

are not used for arm propulsion.

A lever activated drive (E0988) is an alternative drive mechanism for propulsion of a manual wheelchair.

It includes a user‐powered lever arm mechanism attached to one or both wheel hub(s). The lever

activates adjustable ratio gears and has the capability to shift between forward, reverse and braking.

A pneumatic tire (E2211, E2214) is a rubber tire which is used in conjunction with a separate tube

(E2212, E2215) which is filled with air.

A flat free insert (E2213) is a removable ring of firm material that is placed inside of a pneumatic tire to

allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may not be used

for a foam filled tire. Not covered if main purpose is for outdoor use.

A foam filled tire (E2216, E2217) is one in which a rubber tire shell has been filled with foam which is

nonremovable.

A foam tire (E2218, E2219) is one which is made entirely of self‐skinning urethane.

A solid tire (E2220, E2221, E2222) is one which is made of hard plastic or rubber.

A gear reduction drive wheel (E2227) is one that has more than one gear ratio option. Pushing on the

rim allows the user to manually shift between the gears in order to provide additional leverage to assist

propulsion of a manual wheelchair.

A wheel braking and lock system (E2228) is a caliper or disc type braking system that permits the

controlled slowing of a manual wheelchair or the controlled descent on inclines. It also has full wheel

lock capability.

A rear wheel assembly (K0069 and K0070) includes a wheel rim plus a tire. For pneumatic tires, it also

includes the tire tube, but not a flat free insert.

A caster assembly (K0071, K0072, and K0077) includes a caster fork, wheel rim, and tire.

For information concerning a push‐rim activated power assist device for a manual wheelchair, refer to

the power mobility devices medical policy.

POWER SEATING SYSTEMS


24

A power tilt seating system (E1002) includes: a solid seat platform and a solid back; any frame width

and depth; detachable or flip‐up fixed height or adjustable height arm rests; fixed or swingaway

detachable leg rests; fixed or flip‐up footplates; a motor and related electronics with or without variable

speed programmability; a switch control which is independent of the power wheelchair drive control

interface; any hardware that is needed to attach the seating system to the wheelchair base. It does not

include a headrest. It must have the following features: ability to tilt to greater than or equal to 45° from

horizontal; back height of at least 20 in.; ability for the supplier to adjust the seat to back angle; ability to

support patient weight of at least 250 lbs.

A power recline seating system (E1003‐E1005) includes: a solid seat platform and a solid back; any

frame width and depth; detachable or flip‐up fixed height or adjustable height arm rests; fixed or

swingaway detachable leg rests; fixed or flip‐up footplates; a motor and related electronics with or

without variable speed programmability; a switch control which is independent of the power wheelchair

drive control interface; any hardware that is needed to attach the seating system to the wheelchair

base. It does not include a headrest. It must have the following features: ability to recline to greater

than or equal to 150° from horizontal; back height of at least 20 in.; ability to support patient weight of

at least 250 lbs.

A power tilt and recline seating system (E1006 ‐ E1008) includes: a solid seat platform and a solid back;

any frame width and depth; detachable or flip‐up fixed height or adjustable height arm rests; fixed or

swingaway detachable leg rests; fixed or flip‐up footplates; two motors and related electronics with or

without variable speed programmability; a switch control which is independent of the power wheelchair

drive control interface; any hardware that is needed to attach the seating system to the wheelchair

base. It does not include a headrest.

It must have the following features: ability to tilt to greater than or equal to 45° from horizontal; ability

to recline to greater than or equal to 150° from horizontal; back height of at least 20 in.; ability to

support patient weight of at least 250 lbs.

Codes E1002 for power tilt, E1003, E1004, E1005 for power recline, and E1006, E1007, & E1008 for

tilt/recline systems are all inclusive. No separate billing for heavy duty or bariatric features is allowed.

A mechanical shear reduction feature (E1004 and E1007) consists of two separate back panels. As the

posterior back panel reclines or raises there is a mechanical linkage between the two panels which

allows the patient's back to stay in contact with the anterior panel without sliding along that panel.

A power shear reduction feature (E1005 and E1008) consists of two separate back panels. As the

posterior back panel reclines or raises there is a separate motor which controls the linkage between the

two panels and allows the patient's back to stay in contact with the anterior panel without sliding along

that panel.

A mechanically linked leg elevation feature (E1009) involves a pushrod which connects the leg rest to a

power recline seating system. With this feature, when the back reclines, the leg rest elevates; when the

back raises, the leg rest lowers.

A power leg elevation feature (E1010) involves a dedicated motor and related electronics with or

without variable speed programmability which allows the leg rest to be raised and lowered

independently of the recline and/or tilt of the seating system. It includes a switch control which may or


25

may not be integrated with the power tilt and/or recline control(s). It includes either articulating or non‐

articulating leg rests. The unit of service of code E1010 is a pair.

A power seat elevation system (E2300) includes: a motor and related electronics with or without

variable speed programmability; a switch control which is independent of the power wheelchair drive

control interface; any hardware that is needed to attach the seating system to the wheelchair base. It

must provide a seat elevation of at least 6 in.

A power standing system (E2301) includes: a solid seat platform and a solid back; detachable or flip‐up

fixed height arm rests; hinged leg rests; anterior knee supports; fixed or flip‐up footplates; a motor and

related electronics with or without variable speed programmability; a basic switch control which is

independent of the power wheelchair drive control interface; any hardware that is needed to attach the

seating system to the wheelchair base. It does not include a headrest. It must have the following

features: ability to move the patient to a standing position; ability to support patient weight of at least

250 lbs.

Codes E2310 and E2311 describe the electronic components that allow the patient to control two or

more of the following motors from a single interface (e.g., proportional joystick, touchpad, or

nonproportional interface): power wheelchair drive, power tilt, power recline, power shear reduction,

power leg elevation, power seat elevation, power standing. It includes a function selection switch which

allows the patient to select the motor that is being controlled and an indicator feature to visually show

which function has been selected.

When the wheelchair drive function has been selected, the indicator feature may also show the

direction that has been selected (forward, reverse, left, right). This indicator feature may be in a

separate display box or may be integrated into the wheelchair interface. Payment for the code includes

an allowance for fixed mounting hardware for the control box and for the display box (if present).


The term interface in the code narrative and definitions describes the mechanism for controlling the

movement of a power wheelchair. Examples of interfaces include, but are not limited to, joystick, sip

and puff, chin control, head control, etc.

Note: In the power mobility devices policy, the term "control input device" is used instead of

"interface."

A proportional interface is one in which the direction and amount of movement by the patient controls

the direction and speed of the wheelchair. One example of a proportional interface is a standard

joystick.

A nonproportional interface is one which involves a number of switches. Selecting a particular switch

determines the direction of the wheelchair, but the speed is preprogrammed. One example of a

nonproportional interface is a sip‐and‐puff mechanism.

The term controller describes the microprocessor and other related electronics that receive and

interpret input from the joystick (or other drive control interface) and convert that input into power

output which controls speed and direction. A high power wire harness connects the controller to the

motor and gears.


26

A non‐expandable controller has the following features:

May have the ability to control up to two power seating actuators through the drive control (for

example, seat elevator and single actuator power elevating leg rests).

Note: Control of the power seating actuators though the control input device would require the use

of an additional component, E2310 or E2311.

Can accommodate only an integral joystick or a standard proportional remote joystick.

May allow for the incorporation of an attendant control.

An expandable controller is capable of accommodating one or more of the following additional

functions:

Other types of proportional input devices (e.g., mini‐proportional or compact joysticks,

touchpads, chin control, head control, etc.)

Non‐proportional input devices (e.g., sip and puff, head array, etc.)

Operate three or more powered seating actuators through the drive control.

Note: Control of the power seating actuators though the control input device would require the use

of an additional component, E2310 or E2311.

An expandable controller may also be able to operate one or more of the following:

A separate display (i.e., for alternate control devices)

Other electronic devices (e.g., control of an augmentative speech device or computer through

the chair's drive control)

An attendant control

For power wheelchairs which are capable of being upgraded to an expandable controller (K0835 ‐

K0891), E2377 is used if an expandable controller is provided at the time of initial issue. Code E2376 is

used with complete replacement of an expandable controller.

A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required

for the operation of an expandable controller. It also includes all the necessary fasteners, connectors,

and mounting hardware. Code E2313 is separately billable in addition to an expandable controller both

at initial issue and with complete replacement of the expandable controller. Reimbursement is included

in HCPCS codes E2377/E2376 plus E2312. Therefore, code K0108 should not be used. However, if

individual components of the harness are replaced, code K0108 should be used.

A switch is an electronic device which turns power to a particular function either "on" or "off." The

external component of a switch may be either mechanical or nonmechanical. Mechanical switches

involve physical contact in order to be activated. Examples of the external components of mechanical

switches include, but are not limited to, toggle, button, ribbon, etc. Examples of the external

components of nonmechanical switches include, but are not limited to, proximity, infrared, etc. Some of

the codes include multiple switches. In those situations, each functional switch may have its own

external component or multiple functional switches may be integrated into a single external switch

component or multiple functional switches may be integrated into the wheelchair control interface

without having a distinct external switch component.


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A stop switch allows for an emergency stop when a wheelchair with a nonproportional interface is

operating in the latched mode. (Latched mode is when the wheelchair continues to move without the

patient having to continually activate the interface). This switch is sometimes referred to as a kill switch.

A direction change switch allows the patient to change the direction that is controlled by another

separate switch or by a mechanical proportional head control interface. For example, it allows a switch

to initiate forward movement one time and backward movement another time.

A function selection switch allows the patient to determine what operation is being controlled by the

interface at any particular time. Operations may include, but are not limited to, drive forward, drive

backward, tilt forward, recline backward, etc.

An integrated proportional joystick and controller is an electronics package in which a joystick and

controller electronics are in a single box, which is mounted on the arm of the wheelchair.

The interfaces described by codes E2312, E2321, E2322, E2325, E2327 ‐ E2330, and E2373 ‐ E2377 must

have programmable control parameters for speed adjustment, tremor dampening, acceleration control,

and braking.

A remote joystick is one in which the joystick is in one box that is typically mounted on the arm of the

wheelchair and the controller electronics are located in a different box that is typically located under the

seat of the wheelchair. The joystick is connected to the controller through a low power wire harness. A

remote joystick may be used for either hand control, chin control, or attendant control.

A standard proportional remote joystick is one which requires approximately 340 gr. of force to

activate and which has an excursion (length of throw) of approximately 25 mm from neutral position. It

can be used with a non‐expandable or an expandable controller. There is no separate billing for a

standard proportional remote joystick when it is provided at the time of initial issue of a power

wheelchair whether it is used for hand or chin control by the patient or whether it is used as an

attendant control in place of a patient‐operated drive control interface.

A mini‐proportional (short throw) remote joystick (E2312) is one which can be activated by a very low

force (approximately 25 gr.) and which has a very short displacement (a maximum excursion of

approximately 5 mm from neutral). It can only be used with an expandable controller. It can be used for

hand or chin control or control by other body part (e.g., tongue, lip, finger tip, etc.). There is no separate

billing for control buttons, displays, switches, etc. There is no separate billing for fixed mounting

hardware, regardless of the body part used to activate the joystick.

A compact proportional remote joystick (E2373) is one which has a maximum excursion of about 15

mm from neutral position but requires approximately 340 gr. of force to activate. It can only be used

with an expandable controller. It can be used for hand or chin control or control by other body part (e.g.,

foot, amputee stump, etc.) There is no separate billing for control buttons, displays, switches, etc. There

is no separate billing for fixed mounting hardware, regardless of the body part used to activate the

joystick.

A touchpad is an interface similar to the pad‐type mouse found on portable computers. It is coded

K0108.

Code E2321 is used for a nonproportional remote joystick, regardless of whether it is used for hand or

chin control.


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When code E2312, E2321, E2373, or E2374 is used for a chin control interface, the chin cup is billed

separately with code E2324.

Code E2322 describes a system of three to five mechanical switches which are activated by the patient

touching the switch. The switch that is selected determines the direction of the wheelchair. A

mechanical stop switch and a mechanical direction change switch, if provided, are included in the

allowance for the code.

Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick ‐ e.g., U‐

shape or T‐shape ‐ or that have some other nonstandard feature ‐ e.g., flexible shaft.

A sip and puff interface (E2325) is a nonproportional interface in which the patient holds a tube in their

mouth and controls the wheelchair by either sucking in (sip) or blowing out (puff). A mechanical stop

switch is included in the allowance for the code. E2325 does not include the breath tube kit which is

described by code E2326.

A proportional, mechanical head control interface (E2327) is one in which a headrest is attached to a

joystick‐like device. The direction and amount of movement of the patient's head pressing on the

headrest control the direction and speed of the wheelchair. A mechanical direction control switch is

included in the code.

A proportional, electronic head control interface (E2328) is one in which a patient's head movements

are sensed by a box placed behind the patient's head. The direction and amount of movement of the

patient's head (which does not come in contact with the box) control the direction and speed of the

wheelchair. A proportional, electronic extremity control interface (E2328) is one in which the direction

and amount of movement of the patient's arm or leg control the direction and speed of the wheelchair.

A nonproportional, contact switch head control interface (E2329) is one in which a patient activates

one of three mechanical switches placed around the back and sides of their head. These switches are

activated by pressure of the head against the switch. The switch that is selected determines the

direction of the wheelchair. A mechanical stop switch and a mechanical direction change switch is

included in the allowance for the code.

A nonproportional, proximity switch head control interface (E2330) is one in which a patient activates

one of three switches placed around the back and sides of their head. These switches are activated by

movement of the head toward the switch, though the head does not touch the switch. The switch that is

selected determines the direction of the wheelchair. A mechanical stop switch and a mechanical

direction change switch is included in the allowance for the code.

An attendant control is one which allows a caregiver to drive the wheelchair instead of the patient. The

attendant control is usually mounted on one of the rear canes of the wheelchair. This code is limited to

proportional control devices, usually a joystick. Code E2331 is used when an attendant control is

provided in addition to a patient‐operated drive control interface.

Codes E2374 ‐ E2376 describes components of drive control systems. They may only be used for

replacements other than at the time of initial issue.

WHEELS AND TIRES FOR POWER WHEELCHAIRS


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A drive wheel is one which is directly controlled by the motor of the power wheelchair. It may be either

a rear wheel, mid wheel, or front wheel, depending on the model of the power wheelchair.

A caster is a smaller wheel that is in contact with the ground during normal operation of the wheelchair

and which not directly controlled by the motor. It may be in the front and/or rear, depending on the

location of the drive wheel.

A pneumatic tire (E2381, E2384) is a rubber tire which is used in conjunction with a separate tube

(E2382, E2385) which is filled with air. A valve (E2393) is part of the tire tube and is only separately

payable if just the valve is replaced on an existing tire tube.

A flat free insert (E2383) is a removable ring of firm material that is placed inside of a pneumatic tire to

allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may not be used

for a foam filled tire.

A foam filled tire (E2386, E2387) is one in which a rubber tire shell has been filled with foam which is

nonremovable.

A foam tire (E2388 and E2389) is one which is made entirely of self‐skinning urethane.

A solid tire (E2390, E2391, and E2392) is one which is made of hard plastic or rubber.

All types of tires and wheels are included in the code for a power mobility base. Codes E2381 ‐ E2396

may only be used for replacements other than at the time of initial issue.

Code E2351 describes an electronic interface used with a speech generating device.

The Healthcare Common Procedure Coding System (HCPCS) code E1028 is defined as manual

swingaway, retractable, or removable mounting hardware for a joystick, other power wheelchair

control interface, or positioning accessory. Fixed mounting hardware is included in the allowance for

these codes. E1028 represents an incremental up charge when specialty hardware is substituted for

fixed hardware.

Code E1029 describes a ventilator tray which is attached in a fixed position to the wheelchair base or

back. Code E1030 describes a ventilator tray which is attached to the seat back and is articulated so

that the tray will remain horizontal when the seat back is raised or lowered.

Code E1225 describes a manually operated reclining back that can recline greater than 15° but less than

80°.

Code E1226 describes a manually operated reclining back that reclines 80° or greater.

MISCELLANEOUS

The following is an article released by the DME MAC, it is included to assist our providers with

precertification and billing of power wheelchairs. The Health Plan is following this policy unless

otherwise indicated in a contractual document or member’s benefit plan.

Power Wheelchair Electronics Clarification


30

Recently, it has come to the attention of the DME MAC that there is confusion regarding the billing of

wheelchair electronics. This article provides instructions on appropriate billing of power wheelchair

electronics, such as motors, controllers, harnesses, and interfaces.

When one power seating function/actuator/motor is provided on a power wheelchair, only one unit of

E2310 (electronic connection between wheelchair controller and one power seating system motor) is

allowed. An expandable controller (E2377) is not allowed in this situation unless a specialty interface is

used.

Example: E1002 (power seating system, tilt only) is added to a power wheelchair. A power tilt system

uses one power seating motor/actuator.

If two power seating functions/actuators/motors are provided, then one unit of E2311 (electronic

connection between wheelchair controller and two or more power seating system motors) is allowed.

An expandable controller (E2377) is not allowed in this situation unless a specialty interface is used.

Example: E1002 and power elevating leg rests, E1010 (which include articulating or non‐articulating),

are added to a power wheelchair. Each has one actuator or power seating system motor, for a total of

two.

Codes E2377 (expandable controller), E2313 (harness for upgrade to expandable controller and E2311

(electronic connection between wheelchair controller and two or more power seating system motors)

are allowed when three or more power seating system motors are involved.

Example: Power tilt, recline and power elevating leg rests/foot platform involve three power seating

system motors.

An expandable controller (E2377) and the wiring harness (E2313) are also billed when a specialty

interface is required, i.e., head control interface (E2327, E2328, E2329, E2330), sip‐n‐puff interface

(E2325), joystick other than a standard proportional joystick (E2312, E2321, E2373), or multi‐switch

hand control interface (E2322).

There is no separate billing/payment for electronics if a nonexpandable controller and a standard

proportional joystick (integrated or remote) are provided.

Codes E2310 and E2311 describe electronic components that allow the patient to control two or more

of the following motors from a single interface, e.g., proportional joystick, touchpad, or nonproportional

interface:

Power Tilt

Power Recline, with or without shear reduction

Combination Power Tilt and Recline, with or without shear reduction

Power Leg Elevation with or without articulation, power center mount elevating foot platform

with or without articulating properties

The interface includes a function selection switch that allows the patient to select the motor that is

being controlled and an indicator feature to visually show which function has been selected. When the

wheelchair drive function has been selected, the indicator feature may also show the direction that has

been selected (forward, reverse, left, right). This indicator feature may be in a separate display box or


31

may be integrated into the wheelchair interface. Payment for the interface code includes an allowance

for fixed mounting hardware for the control box and the display box, if present.

A harness (E2313) describes all the wires, fuse boxes, fuses, circuits, switches, etc. that are required for

the operation of an expandable controller (E2377). It also includes all the necessary fasteners,

connectors, and mounting hardware.

There is no separate billing for control buttons, displays, switches, etc. There is no separate billing for

fixed mounting hardware, regardless of the body part used to activate the joystick.

AMA CPT/ADA CDT COPYRIGHT STATEMENT

CPT only copyright 2002‐2017 American Medical Association. All Rights Reserved. CPT is a registered

trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee

schedules, relative value units, conversion factors and/or related components are not assigned by the

AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or

indirectly practice medicine or dispense medical services. The AMA assumes no liability for data

contained or not contained herein.

INTERNET LINKS AND SOURCES

National Government Services website. Medical Policy Center. Durable Medical Equipment. Wheelchair

Options/Accessories. Local Coverage Determination L27223 and Article A47229. Jurisdiction B. Last

accessed 05/01/14. Retrieved from apps.ngsmedicare.com/applications/lcd.aspx?CatID=3&RegID=51

CGS Medicare: A Celerian Group Company. Wheelchair Options/Accessories. Local Coverage

Determination Policy. L33792 and Article A52504. Jurisdiction C. Last accessed 04/21/17. Retrieved from

cgsmedicare.com/jc/coverage/lcdinfo.html

West Virginia Medicaid Internet Provider Manual. Chapter 506. Durable Medical Equipment, Prosthetics,

Orthotics and Supplies (DMEPOS). Last accessed 06/01/16. Retrieved from

http://www.dhhr.wv.gov/bms/Pages/Chapter‐506‐Durable‐Medical‐Equipment%2c‐Prosthetics%2c‐

Orthotics‐and‐Supplies‐%28DMEPOS%29.aspx

The Pricing, Data Analysis, and Coding Contractor. Noridian. Internet website. Last accessed 06/01/16.

Retrieved from dmepdac.com/dmecsapp/do/search

The Health Plan Provider Procedural Manual. Payment Voucher, Section 14, Page 11

Department of Health and Human Services DEPARTMENTAL APPEALS BOARD Appellate Division. CMS

LCD COMPLAINT: Wheelchair Options/Accessories (LI1462) Docket No. A‐II‐50 Decision No. 2389 June

20, 2011. Final Decision on review of Administrative Law Judge Decision. Last accessed 06/01/16.

Retrieved from hhs.gov/dab/decisions/dabdecisions/dab2389.pdf

Noridian Healthcare Solutions. Medicare Pricing, Data Analysis and Coding (PDAC) Contractor. Advisory

Article. Manual Wheelchair Bases. Last accessed 06/01/16. Retrieved from

dmepdac.com/resources/articles/2013/10_01_13b.html

Face‐to‐Face Examination and Prescription Requirements Prior to the Delivery of Certain DME Items

Specified in the Affordable Care Act DME MAC Joint Publication. Posted February 20, 2014. Last

accessed 06/01/16. Retrieved from medicarenhic.com/viewdoc.aspx?id=2580


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Dept. of Health and Human Services. Centers For Medicare and Medicaid services. Denial for Power

Mobility Device Claim from a Supplier of a Durable Medical, Orthotics, Prosthetics, and Supplies When

Ordered by a Non‐ Authorized Provider. Last accessed 06/01/16. Retrieved from

https://www.cms.gov/Outreach‐and‐Education/Medicare‐Learning‐Network‐

MLN/MLNMattersArticles/Downloads/MM8239.pdf

CGS. A Celerian Group Company. Cantilever Type Armrest. Correct Coding. DME MAC Joint Publication.

July 28, 2016. Last accessed 10/04/16. Retrieved from:

http://www.cgsmedicare.com/articles/cope33574.html

wheelchair options/accessories - health plan options/accessories ... e2209 accessory, arm trough,...

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